Relaxology and Repair Hydrotherapy Scalp Head Spa Massage Consent Form

Relaxology & Repair By Kimberly Massage and Head Spa Consent Form
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Email
example@example.com
Phone Number
Preferred method of contact

Phone callTextEmail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
How did you hear about us?
Important Information and Policies
Cancellation Policy:

Please cancel your appointment at least 24 hours in advance to avoid a 50% cancellation fee. As all massage treatments are by appointment only, a major credit card or debit card is required to secure your reservation. You will only be charged upon receiving your service or if you fail to cancel within 24 hours or do not show up for your appointment. In such cases, if you fail to cancel within the 24 hour window you will be charged 50% of the amount of the service booked. If you cancel on the same morning as your appointment or do not show up, you will be charged 100% of the service scheduled.

You will receive a reminder/confirmation text 48 hours prior to your appointment.

Cash Payment Discount: You will receive a 4% discount when paying in cash. All services have a 7.25% state sales tax applied. An additional 4% processing fee is applied to credit or debit card purchases. To avoid this 4% fee, you may pay in cash.

Late Arrivals:

To fully enjoy all that your massage session has to offer, I encourage you to arrive at least 5 minutes prior to your treatment. This allows you time for using the restroom and getting settled in. As your treatment time is reserved exclusively for you, arriving late will shorten your experience. If sessions start late, you will be financially responsible for the original booking duration amount, regardless of duration given.

Spa Address: 47345 National Rd. W, St. Clairsville OH - the spa is located in the building that is further back with the pink and black sign that says Revival Salon and Spa.

Self-serve Blow Dry Station (Headspa Clients only):

Upon completion of your head spa service, your hair will be neatly wrapped in towel. A complimentary self-serve blow dry station is available for your use.

If you would like to elevate your spa experience, be sure to book a blow out with one of our wonderful Revival hair stylists at the salon in advance.

Hair Extensions:

At this time, I am unable to provide full head spa scalp cleansing services to clients with hair extensions. For clients with hair extensions, I can still perform the headspa treatment, there will just be greater emphasis on massage and relaxation rather than a deep scalp cleanse.

Ensuring a safe and respectful environment:

I prioritize creating a safe and comfortable space for all clients to enjoy their massage experience. I uphold a zero tolerance policy towards any form of inappropriate behavior.

I hold myself to the standard of maintaining a professional and therapeutic environment at all times. If a client engages in behavior that is disrespectful, offensive, or violates my code of conduct - they will kindly be asked to leave, with their session immediately terminated, without a refund.

Thank you for your understanding and cooperation in helping maintain a safe and welcoming space for all.
Emergency Contact Details
In case of emergency, we will contact the person below:
Emergency Contact Name

First NameLast Name
Phone Number
Relationship
Health Data
Do you have any allergies?
If yes, please specify on the field above.
Are you currently taking any medications?
If yes, please specify on the field above.
Are you pregnant or nursing (females only)

yesno
If yes, how far along?
Any high risk factors? (Pregnant Women Only)
Have you been recently hospitalized?
If yes, please specify on the field above.
Do you suffer from Chronic pain?

yesno
If yes, please explain
What makes it better?
What makes it worse?
Do you have any current injuries?
If yes, please specify on the field above.
Any recent surgeries/procedures?
Please indicate if you have any of the following that apply to you:

CancerHeadaches/MigrainesArthritusDiabetesHigh Blood PressureLow Blood PressureNeuropathyFibromyalgiaStrokeHeart DiseaseKidney dysfunctionBlood ClotsNumbness/TinglingSprains or StrainsBruise easilyCarpal TunnelTMJInsomniaSeizures/EpilepsyCirculatory problemsNerve DamageSciaticaHerniated/Bulging DiscsScoliosisMultiple SclerosisAuto Immune DiseaseSkin DiseaseJoint ReplacementNONE OF THE ABOVE
Explain any conditions you have marked above:
Are there any conditions that are not listed above?
Have you had a professional massage before?

yesno
What pressure do you prefer for your massage?

LightMediumFirmDeep
Do you have have any allergies or sensitivities to oils, lotions, or essential oils?

Yesnonot sure
If yes, please explain:
What are your goals for this treatment session?
This section only applies to head spa clients. Leave blank and skip to the bottom if it does not apply to your service. When was the last time you colored/permed/chemically straightened your hair?

In the Last 3 DaysIn The Last MonthIn The Last 3 MonthsOver 3 months agoNever
How would you describe your scalp/hair?

DryOilyNormalCombinationOther
Are you currently suffering from any of the following conditions?

Dry/DandruffOilyItchyOdorIrritated/SensitiveKnotting/Matting EasilySeborrheic DermatitisPsoriasisEczemaNone of the AboveOther
Do you have any of the following concerns with your hair?

Hair thinningHair LossSplit EndsDry/Damaged
How often do you wash your hair?
Desired Water Temperature For Your Headspa Treatment

LukewarmRegularHot
Consent and Waiver
PLEASE NOTE:

Licensed Massage Therapists cannot diagnose or cure any illness or disease. By providing my signature at the end of this form, I am confirming I have completed this form to the best of my knowledge and agree to inform my therapist of any changes to my health
I, undersigned, agree with the following statements:

I authorize the licensed massage therapist, Kimberly Cline, at Revival Salon and Spa to perform the requested massage treatment.I have read the policies on cancellations, late arrivals, and the zero tolerance policy for inappropriate behavior to ensure a safe and respectful environment for everyone.I acknowledge that I have consulted a physician before undergoing this massage treatment. I understand that I should consult my doctor before the procedure.I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician.I release this massage spa center for any responsibility in case of an accident, illness, or injury.I acknowledge that all information I provided in this form is true and accurate.
Signature of the Client

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

Relaxology & Repair By Kimberly Massage and Head Spa Consent Form

Important Information and Policies

Emergency Contact Details

Health Data

Consent and Waiver